This case study examines a 16.5-year-old male adolescent who
engages in fire setting, severe aggression and self injurious and
impulsive behaviors. He was treated with Mode Deactivation Therapy (MDT)
for four months and his problem behaviors have been reduced
significantly. He was previously treated with Dialectical Behavior
Therapy (DBT). It appears that in this case study MDT was effective in
reducing his severe behaviors.

After a thorough literature review this appears to be the first
case study that examines the effects of MDT with an adolescent with fire
setting behaviors.

Case Summary

This case analysis is a step-by-step case study, with a
corresponding theoretical analysis based in mode deactivation therapy
(MDT). The methodology known as MDT suggests potential for effective
treatment of youngsters with similar backgrounds as Peter. Peter is a
16.5-year-old Caucasian male. He has been diagnosed with Post Traumatic
Stress Disorder, Conduct Disorder and Personality Disorder Traits. Peter
demonstrated a pattern of continuous disruptive behaviors including;
fire setting, lying, social phobia, aggressive and threatening
posturing, property destruction, academic performance problems and
school behavior problems, peer relationship problems and torturing
animals. He also has tortured animals in front of other children and he
had a history of early sexual experience, specifically sexual touching
of other children.

Client Family History

Peter had demonstrated significant behavioral and impulsive
problems since early childhood, which were manifested more prominently
when he was four. During this time he was removed from his mothers care
due to her continuous substance abuse. She reported using alcohol,
cocaine, and crack cocaine during her pregnancy. He was the second
youngest of six children all of whom have delinquent problems and are in
Department of Social Services custody or involvement in some way. He was
placed with his grandmother who also failed to provide adequate
supervision; as a result he was removed from her care. From 2000 to 2003
he was placed in nine inpatient settings, including residential
placements and hospitals. He was removed from most of the nine
placements due to disruptive, aggressive, suicidal behaviors.

Peter preformed at the normal grade level at school, but he
required increased structure and individualized attention. Peter has a
history of repeated violations of school rules and disruption in class.
He often was aggressive and cut school.

He was placed briefly at a hospital then moved to a residential
setting on an island. Within a couple of days, out of staff supervision
he started a fire, which destroyed over 40 acres of protected woodlands.
This led to his brief placement as an inpatient at a local Hospital
prior to being admitted. Upon admission he has disclosed for the first
time the he was sexually abused (repeated anal rape) by a 16 year old
male cousin, in his grandmother's home, for several years starting
at the age of seven. He reported that he told his grandmother, who did
not believe him and punished him as a result of his disclosure. Later
one of his older sisters eventually believed him and reported the crime.
He was subsequently removed from her home, and the cousin was
incarcerated. Peter also reported torturing animals and doing
"sexual things" to them. He also reported that he set his
grandmothers bed on fire while she was sleeping in it. Another
disclosure involved playing in the back yard of his grandmother's
home where he burned several toys.

Psychological testing was carried out in 2002 and his results
indicated an average IQ using the Wechsler Intelligence Scale for
Children-3rd edition. His scale scores included a verbal score of 93,
performance score of 104 and a full scale score of 95. Further testing
revealed his struggles with an extremely low self-esteem. He also
provided somewhat odd answers on a sentence completion assessment,
mentioning several times "that I wish I was never born".

Axis IV: Problems with primary support system, the social
environment, educational problems. Sexual Abuse of a Child (victim and
offender issues)

Axis V: Highest GAF past year: 45

Current GAF: 50

Admission GAF: 45

Mode Deactivation Therapy (MDT) Case Conceptualization

Underlying the MDT methodology is the MDT Case Conceptualization.
MDT Case Conceptualization is a combination of J.S. Beck's (1995)
case conceptualization and Nezu, Nezu, Friedman, and Haynes's
(1998) problem solving model, with several new assessments and
methodologies recently developed to address the specifics of
adolescents.

Case conceptualizations include the presenting problems, test data,
cultural issues, history and development, cognitive issues, and
behavioral issues (Friedberg & McClure, 2002). The MDT Case
Conceptualization takes conceptualizing a case a step further. The MDT
Case Conceptualization helps the clinician examine underlying fears of
the youth. These fears serve the function of developing avoidance
behaviors in the youngster. These behaviors usually appear as a variety
of problem behaviors in the milieu. Developing personality disorders
often surrounds underlying post traumatic stress disorder (PTSD) issues.
The MDT Case Conceptualization method provides an assessment for the
underlying compound core beliefs that are generated by the developing
personality disorders; it is known as the Fear Assessment.

Thus far, preliminary results suggest that this typology of
youngsters have a conglomerate of compound core beliefs associated with
personality disorders. This conglomerate of beliefs may be a personality
disorder reason why many youngsters fail in treatment. One cannot treat
specific disorders, such as aggression, without gathering these
conglomerate beliefs. It is also apparent that these beliefs are not
cluster specific as suggested by Beck, Freedman, Davis and Associates,
2004. That is to say, that the conglomerate of beliefs and associated
behaviors contains beliefs from each cluster that integrate with each
other. Because of this complex integration of beliefs, it makes
treatment for this typology of youngster more complicated. The
conglomerate of compound core beliefs represents protection for the
individual from their vulnerability issues, which may present behaviors
that interfere with treatment The attempt to use the usual didactic
approaches to treatment, without addressing these beliefs amounts to
treatment interfering behavior on the part of the psychologist, or
treating professional, is not empirically supported and
counter-initiated. The MDT Case Conceptualization provides a functional
treatment methodology that integrates into the treatment plan. The MDT
Case Conceptualization also provides a methodology to identify and
address the reactive adolescent's emotional dysregulation. The
emotional dysregulation refers to the Linehan (1993) model of the
Borderline Personality Disorder (BPD) emotional dysregulation,
integrated with the Reactive Conduct Disorder (Dodge, et al, 1997).

Peter's Fear Assessment Results

The Fear Assessment is a sixty question measure designed to
identify fears and anxieties that are interfering to the clients life
and treatment. The Fear Assessment is a measure designed as one of the
cornerstones of MDT treatment. These Results from the Proactive Fear
Assessment suggest that Peter is an individual who has anxiety and fear
that relates to external areas or things outside of himself, over which
he has little or no control. Endorsed fears indicate that Peter'
behavior is in response or reaction to external stimuli, which he
perceived as threat, which appears to validate his history of sexual
exposure and abuse. He endorsed fears of trusting a relative,
specifically his mother and grandmother. He had fears of being in a
closed room with them, being emotionally alone, or them doing something
sexual to him. His fears also included his cousin and his anxiety of
failing in life. He had further anxiety about past incidents and
believing that he did something wrong. Because of these fears and
anxieties centering on his victimization, he developed fears of engaging
in emotionally intimate relationships. PTSD symptoms included his fears
of being dumb, of going to bed and of being weak. Other self defeating
beliefs included his belief that he caused the problem, no one will
believe him if he disclosed the abuse and of being alone in the world.
He had significant fear of his feelings, someone coming up behind him,
of being touched by someone that he doesn't know well, confronting
his abuser and being physically hurt for no reason. Finally, further
fears became manifest with the fear assessment including the fear of
hurting someone and loosing control, of having sexual contact and of
being locked or restricted in a room. These fears were matched with
corresponding beliefs to complete the Trigger, Fear, Avoids, Beliefs
(TFAB) worksheet.

The Compound Core Beliefs Questionnaire (CCBQ) suggests that Peter
has a personality disorder NOS--with mixed features of antisocial,
borderline, paranoid, antisocial, histrionic, narcissistic, and
obsessive-compulsive. He endorsed numerous beliefs of the borderline
personality. Many of these beliefs appear to have gone untreated by the
previous therapists. Examining his beliefs indicates that Peter'
sexual aggression and oppositional behavior are related to his
dichotomous borderline beliefs and emotional dysregulation. He endorsed
the following compound core beliefs as occurring always "Whenever I
hope, I will be disappointed," "Other people have hidden
motives and want something from me," "If you criticize me, you
are against me," "When I am angry, my emotions are extreme and
out of control," "If I am afraid something will be unpleasant,
I will avoid it," "When I hurt emotionally, I do whatever it
takes to feel better," "Life at times feels like an endless
series of disappointments followed by pain," "I can not trust
others--they will hurt me," "If I trust someone today, they
will betray me later," "If I let others know information about
me, they'll use it against me," "If I act silly and
entertain people, they won't notice my weaknesses," "When
I hurt emotionally, I do whatever it takes to feel better,"
"When I'm in pain, I'll do whatever I need to do to feel
better," "I would rather not try something new then fail at
something," "I am happiest when people pay attention to
me," "When I'm angry, my emotions are extreme and out of
control," "If I'm afraid something will be unpleasant, I
will avoid it," "If I'm not on guard, others will take
advantage of me,"

Case Conceptualization

The MDT Case Conceptualization is designed to individualize treatment based on empirically based assessments. The MDT Case
Conceptualization also provides a methodology to address the reactive
adolescent emotional dysregulation typical of adolescents with conduct
and personality disorder. The typology of these adolescents often
demonstrates aggressive and destructive reactions through emotions to
threats or perceived threats. The case provides the structure of the
conglomerate of beliefs and behaviors to address the dysregulation by
balancing the beliefs.

The conglomerate of beliefs and behaviors identifies behaviors that
correlate with beliefs and is the structure needed to work with the
youngster. This provides a method to relate the emotional dysregulation
to the beliefs. The goal is to teach the youngster to balance beliefs by
recognizing that they activate the emotional and behavioral
dysregulation.

Once the information is gathered and the case is formulated, the
client and the therapist collaboratively develop the Conglomerate of
Beliefs and Behaviors (COBB). The collaborative nature of this process
allowed Peter an opportunity to gain trust in his therapist as well as
in himself. By empowering him to actively participate in the development
of his MDT Case Conceptualization and the course of his treatment, he
became significantly more motivated in participating in his treatment.
Peter remarked as to the amount of his beliefs, which tended to
correspond with most of his negative behaviors. He demonstrated insight,
recognizing that resolving his compound core beliefs would enable him to
address his negative behaviors. He was pleased with this realization and
expressed optimism for true change and relief.

The Conglomerate of Beliefs and Behaviors (COBB) is the crux of
treatment for the client. Once he collaboratively validates the Triggers
[right arrow] Fear [right arrow] Avoids [right arrow] Compound Core
Beliefs (TFAB) and begins this form, he helps validate his behavior
responses that are congruent with his compound core beliefs. The COBB
remains with him throughout treatment and is the basis for all of his
work in the MDT Workbook. Peter recognized that these beliefs could be
activated throughout his lifetime and he continually works to deactivate
his fears, by balancing his beliefs. The MDT Case Conceptualization
includes a situations worksheet, real life examples, to test the
"hypotheses" developed with the COBB and TFAB.

After completing the COBB and TFAB, the MDT Case Conceptualization
moves to address mode activation and the deactivation of modes.
Following through the mode activation worksheet and inserting the
already identified information into the appropriate boxes, Peter
experience became clearer. The deactivation of Peter's modes was
evident. Addressing his unbalanced, dichotomous beliefs, would prevent
the rest of the sequence from occurring. This meant that by balancing
his beliefs, Peter could prevent his negative behavior from happening.

If Peter perceived that he could be in a situation where he may be
confronted or reprimanded, his anxiety would increase and he would
emotionally shut down. Anticipating the confrontation set in motion the
cognitive, affective, behavioral, and physiological processes.

Although Peter may not be consciously thinking about confrontation
(and may actually be focused on another activity), an attempt to elicit
his thought at this point would generate the same information as if he
were actively thinking about the anticipated event. He would express
anger about the upcoming perceived confrontation or attack on his
vulnerability and he would be able to discuss that he has a dichotomous
belief that had been activated. He would be able to identify the fear
that was endorsed related to his anger and that he perceived physical
danger from the perceived upcoming situation. As the time of the
perceived confrontation fears, he would have a conscious fear or threat
of being a victim and was also fearful that he would become verbally
and/or physically aggressive to protect himself. The situation appeared
threatening (real or perceived) based on his life's experiences. He
was fearful of his own actions in this situation and worried that he
would later feel humiliated by the outcome of the situation.

At a later time, when Peter is no longer confronted with the
dangers of the situation, he is not experiencing the fears of the
perceived situation. The distance from the dangerous situation
represents the Woody and Rachman, (1994) concept of a "safety
signal." When the parameters of the same situation recur the
pattern of fears avoids beliefs is repeated.

Reviewing the fear reaction pattern in Peter, using A.T.
Beck's (1996) analysis of modes, the activating circumstances are
directly related to the anticipated event and the perception of the
re-victimization of the meeting. These circumstances are processed
through the orienting component of the "primal mode relevant to
danger"--the imagined risk of being victimized, beaten and letting
someone else control him. As this related fear is activated, the various
systems of the mode are also activated and energized. During the
physiological manifestation of the activation of the mode, Dan becomes
tense, grinds his teeth, has involuntary muscle movements, increasingly
intense headaches, tightened facial muscles, his hands and legs shake
and move around, anxiety increases, and his fists may tighten.

The actual progression of the mode activates as Peter nears the
time of the group or meeting, i.e., his orienting schemas signal danger
ahead. This system is based on the perception of danger of
victimization/ vulnerability and is sufficient to activate all the
systems of the mode. The affective system generates rapidly increasing
levels of anxiety; the motivational system signals the impulse and the
flight/fight signal, increasing the attack or avoid and the
physiological system, which produces the following: grinding of his
teeth, involuntary muscle movements, tachycardia, etc.

Peter became aware of his distressing feelings at this point and he
is often unable to activate his own cognitive controls, or
"voluntary controls" to override this "primal"
reaction to be able to mediate the conflict. Once he is able to mediate
the fears and avoidance, he is able to participate in a supportive
meeting and the anxiety begins to de-escalate.

Peter's interpretation of his physiological sensations
magnifies his fears of the anticipated physical and psychological
re-victimization. Throughout the process of the feedback that he
received from his bodily sensations, the flush anxious feelings, the
powerful fear of loss of control and the sequel of physiological
responses develops the fear of yelling and screaming and potential
aggression and a disastrous situation. This fear is compounded by the
events that led to another fear, which is the fear of feeling humiliated
by the perceived threat of victimization/ vulnerability and loss of
control in the presence of other people.

In Peter' case, he was able to develop healthier beliefs due
to his therapist and all staff members working with him using the V-C-R
as described in his treatment plan, originating from his Functionally
Based Treatment Development Form. For example, take Peter' belief
about not being able to trust anyone outside the family. Validating his
fears of trusting anyone outside of the family, clarifying that he could
trust one person outside the family at a time, and redirecting him to
use the trust scales to objectively to measure his level of trust for
others allowed Peter to open his mind to possibilities, thereby
balancing his beliefs about trust. The process also taught Peter how to
balance his beliefs for himself. As a result, he developed a new belief,
to trust some people some of the time.

Results

Peter's residential treatment milieu included and individual
therapy once a week and Psycho-educational model (PEM) Social Skills
training both during school and on the residential unit.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

After 15 months with limited progress in reducing his number of
holds and aggressive behaviors, Peter was transferred into MDT. Shortly
after starting MDT Peter's holds reduced by an average of 57.1 %,
per month, along with his physical aggression and sexual aggression
behavior which were reduced by 37.1 % and 53.3 % respectively.

Discussion

This case study suggests that in at least this case, MDT was more
effective than DBT in reducing physical aggression and self injurious
behaviors. This is not suggesting that MDT is superior to DBT other than
in the results of this case study. However, MDT was developed for this
type of youngster and there is data suggesting that it is a promising
psychotherapy for adolescents. Treating adolescents with conduct and
personality disorders is a difficult task. Many studies reporting
success in treatment of specific personality and/or conduct disorders
seem ineffective in cases of both conduct and mixed personality
disorders. It is hoped that MDT will continue to develop as an effective
psychotherapy for this specific population.

The authors hope to continue to develop MDT and conduct randomized
studies to test it's effectiveness with DBT and other
interventions.

References

Alford, B.A. and Beck, A.T. (1997). The integrative power of
cognitive therapy. New York: Guilford Press.

Apsche, J.A. and Ward Bailey, S.R. (2004a). Mode Deactivation
Therapy: Cognitive-behavioural therapy for young people with reactive
conduct disorders or personality disorders or traits who sexually abuse.
In M.C. Calder (Ed.), Children and Young People who Sexually Abuse: New
Theory, Research and Practice Developments, pp. 263-287. Lyme Regis, UK:
Russell House Publishing.